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M <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY N <br />FACILITY ADDRESS: 4 qq <br />*Vzr.- <br />TANK ID N39 - ISO2w2ft TANK SIZE: X0000 PREVIOUS TANK CONTENTS:rD/FSLZ- F414&4 <br />############rt#####+##rt####++######+##M########**#+#+##rt#####+##++####k###irt####rt###i#+##rt####ww#wwwwwrtwww*♦ <br />SECTION 2 - To be filled out by tank <br />removal <br />contractor: <br />Tani: Removal <br />Contractor: �J byn(.. �iJ�' T�' 442' <br />Address: 0026 Lojeewmg Ave iG/ 3 City: zip: 495-z/0 <br />Phone N: (AW—) �.i4"r) _ Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: A.e ewe' P-/2ae ?-/0A"0?-/0A"0�6 <br />Address: � C24 oRW41V6 +0 24City Zip: OISW40 <br />PhoneN:(�(.�1) 944x02"03 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: <br />Title: Signature: <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and//or piping. <br />Facility Name: J40r64-T77 <br />Address;W Al. Wo9V � � <br />Q' City:r04"Coov— zip: 7/ <br />Phone k: ( 499) e06 R- <br />Date Tank Received: <br />Name: <br />EH 23 046 (Revised 9/11/96) Page 10/'L <br />Date <br />